Yas a R in New York State

Keep this booklet for reference. Review it carefully and share the information with your family and friends involved in your care. Keep this booklet for reference. Review it carefully and share the information with your family and friends involved in your care. The state and federal governments require that all hospital in New York State be given certain information and materials when admitted to a hospital. This booklet collects that information in one place, explains the rights of each hospital patient and contains advice for the patients on how best to get assistance. The booklet is divided into two sections: • The first section of this booklet explains the rights of each hospital patient in New York State. It also contains a Glossary to help understand terms commonly used in the hospital. • .The second section provides documents the law requires the hospital to provide to each patient while in a hospital in New York State.

Questions or Comments: [email protected] Contents

About Your Rights 2 About Your Special Needs ...... 2 Concerns/Problems/Complaints About Your Hospital Care ...... 3 If You Think You Are Being Asked to Leave the Hospital Too Soon 4 You Have the Right to File a Complaint About: Doctors or Assistants ...... 5 Other Professionals 5 Questions or Complaints About Your Hospital Bill or Health Insurance ...... 6 Access to Your Medical Records ...... 7 Glossary 8 Regulations and Information ...... 12 Patients’ Bill of Rights ...... 13 An Important Message Regarding Your Rights as a Hospital Inpatient (for patients not covered by Medicare) ...... 14 Admission Notice for Medicare Patients 16 Important Message from Medicare 17 Deciding about Health Care: A Guide for Patients and Families ...... 21 Introduction ...... 22 Adult Patients Who Have the Ability to Make Informed Decisions ...... 22 Advance Directives/Health Care Proxies ...... 22 Health Care Decision-Making in , Homes and Hospice 23 Decisions to Withhold or Withdraw Life-Sustaining Treatment 24 Decision-Making Standards for Legal Guardians and Surrogates ...... 25 Resolving Disputes ...... 27 DNR Orders Outside the Hospital or 28 Appointing Your Health Care Agent—New York State’s Proxy Law 29 Letter from the New York State Department of Health (SPARCS data collection system) 37 Maternity Information ...... 38 Domestic Violence: Notice for Prenatal and Maternity Patients 39 Domestic Violence: Victim’s Rights Notice 41 Parents’ Bill of Rights 43

1 About Your Rights

As a patient in a New York , you have certain rights and protections guaranteed by state and federal laws and regulations. These laws and regulations help ensure the quality and safety of your hospital care. To help you understand your rights, the New York State Department of Health developed this booklet. Keep this booklet for reference. Review it carefully and share the information with family and friends involved in your care. You have the right to participate in decisions about your health care and to understand what you are being told about your care and treatment. For example, you are entitled to a clear explanation of tests, treatments and drugs prescribed for you. Don’t hesitate to ask questions of your doctor, nurse or hospital staff members. You have a right to know what’s going on. Every patient is unique, every hospital stay is different. It is important to know what specific rights apply to you and what to do if you feel you need help. Some rights and protections, such as those that govern when you leave the hospital, depend on receiving correct written notices. You will also be provided with information explaining when and where to call or write for help. If you have a problem or if you don’t understand something, speak to your nurse, doctor, social worker or patient representative. They can: • help you get answers; • arrange special help; • make contacts with your family; • get foreign language and sign language interpreters; and • generally make your hospital stay easier.

About Your Special Needs Each hospital must make staff available to explain or answer questions about your rights and to provide information on how you can protect those rights. • If you are hearing or vision impaired, or if English is not your first language, skilled interpreters must be provided to assist you. Translations and/or transcriptions of important hospital forms, instructions and information must be provided to you if you feel you need them. But you must speak up and ask questions. You can contact a patient representative before you enter the hospital to be sure your special arrangements are made when you get there. • If you have a question about any of the information in this booklet or feel that your needs have not been adequately met, ask the patient representative or other hospital staff person for further explanation or contact the New York State Department of Health (see page 3).

2 Concerns/Problems/Complaints About Your Hospital Care If you have a concern, problem or complaint related to any aspect of care during your hospital stay, speak to your doctor, nurse or hospital staff member. If hospital staff has not resolved the problem, you may contact the New York State Department of Health by mail or phone. You may call the toll-free number 1-800-804-5447 or you may file a complaint in writing and send it to: New York State Department of Health Centralized Hospital Intake Program Mailstop: CA/DCS Empire State Plaza Albany, NY 12237

3 If You Think You Are Being Asked to Leave the Hospital Too Soon. . . You have the right to appeal decisions made by your doctor, hospital staff or your managed care plan: • about when you are to leave the hospital; • if you feel you are being asked to leave the hospital too soon; • if you believe you have not been given adequate or appropriate plans for your medical care and other services you may need after you leave the hospital; or • if needed services are not in place. The law requires that you receive advance notice in writing telling you: • the date the physician and/or hospital plans to discharge you; • how to appeal if you wish to remain in the hospital; and • a special number to call with any problems related to leaving the hospital.

See page 14 for more information.

For Assistance/Help There is an Independent Professional Review Agent (IPRA) for your area and your insurance coverage. Should you need assistance/help from the IPRA, the hospital will provide you with a phone number/person to contact. See page 9 and 15 for more information.

For Medicare Patients Only If you feel that you are being asked to leave the hospital too soon and have not received advance notice telling you when to leave the hospital, ask for your discharge notice (called “The Important Message from Medicare about Your Rights”). If you are in a Healthcare Maintenance Organization (HMO), you should also request “The Important Message from Medicare about Your Rights”. You must have this written discharge notice in order to appeal the physician’s and hospital’s decision about when you are to leave. See an “Important Message from Medicare about Your Rights” on page 17 for a complete explanation.

For Managed Care Patients If you are a patient enrolled in an HMO or managed care plan, first request/submit an expedited appeal to the HMO or plan’s utilization review committee if you feel your benefits are unfairly limited or denied, or you are being asked to leave the hospital too soon, or that medically necessary services are inappropriately excluded from your coverage. If you are not satisfied with the outcome of that appeal request, you may contact the New York State Department of Health by calling the Bureau of Managed Care Certification and Surveillance at1-800-206-8125.

The Managed Care Law of 1996 amending Public Health Law 4408, Disclosure of Information.

4 You Have the Right to File a Complaint About

• Doctors or Physician Assistants If you feel that you have received incompetent, negligent or fraudulent care from a doctor or physician assistant, you may file a report with the New York State Department of Health Office of Professional Medical Conduct (OPMC). OPMC investigates all reports of possible professional misconduct by and physician assistants. Reports must include the full name and address of the doctor or physician assistant and all relevant information. Reports must be made in writing to: New York State Department of Health Office of Professional Medical Conduct Intake Unit Riverview Center 150 Broadway, Suite 355 Albany, NY 12204-2719 For more information or to obtain a complaint form, call 1-800-663-6114 or visit the Department of Health website at health.ny.gov/professionals/doctors/conduct/ Reports are kept confidential. An investigation may result in a formal hearing before a committee of the Board for Professional Medical Conduct. The Board consists of physicians and consumer members appointed by the Commissioner of Health. See page 10 of the Glossary for examples of “medical misconduct” by a doctor or physician assistant.

• Other Health Care Professionals If you feel you received incompetent, negligent or fraudulent care from any other licensed health care professionals, such as nurses, midwives, dentists, social workers, optometrists, psychologists, physical or occupational therapists and podiatrists, you may file a complaint by contacting: New York State Education Department Office of Professional Discipline 475 Park Avenue South 2nd Floor New York, New York 10016 1-800-442-8106

5 Questions or Complaints About Your Hospital Bill or Health Insurance • As a hospital patient, you are entitled to an itemized bill. • Your hospital bill may identify a charge called a “surcharge.” These surcharges fund important public programs and have existed in previous years, although they may not have appeared as separate costs on the bill. The surcharge represents an additional amount due on total hospital bills in New York State and, depending on your insurance contract, New York State law allows a portion of these costs to be billed to you. • Hospitals negotiate payment rates with insurers, HMOs and other types of managed care plans, as well as commercial insurers and self-insured groups. These rates may vary. Contact your insurer with any questions you may have regarding your coverage.

If you have questions about your coverage, the services billed or amounts paid, contact the hospital’s billing office and your insurer to resolve any questions/problems that you may have.

For Medicare Patients If you are a Medicare patient and have questions about your hospital bill, call Medicare: 1-800-MEDICARE (1-800-633-4227)

For Managed Care Patients If you are enrolled in a managed care plan and you are having trouble getting care or feel your care is not satisfactory, you may complain to the plan. The plan’s handbook MUST tell you how to complain and how to get an immediate review. If you are not satisfied with the HMO or plan’s response to your complaint, contact the New York State Department of Health at: 1-800-206-8125 Medicare managed care enrollees may call Livanta: 1-866-815-5440

6 Access to Your Medical Records New York State law requires all health care practitioners and facilities to grant patients access to their own medical records. Section 18 of the Public Health Law contains procedures for making these records available and the conditions under which a provider can deny access. Patients may request information, in writing, as may parents or guardians who have authorized their child’s care. If you want to see your medical records, ask your doctor and/or the director of medical records at the hospital. New York State law guarantees you the opportunity to inspect your medical records within 10 business days of your written request. If you want to have a copy of your medical records, you must submit a written request to the hospital. Address the request to the Director of Medical Records at the hospital. If you request a copy of your records, the hospital may charge you up to 75 cents per page. If the hospital fails to acknowledge or act on your request, you may complain to the Department of Health by calling 1-800-804-5447. If you have been denied access to all or part of your hospital records, you may appeal to the New York State Department of Health Medical Records Access Review Committee. The hospital/doctor is required to provide a form (DOH-1989) that gives the reason(s) for denial and information on this appeals process. The provider is required to provide the form and complete it under Section 18 of Public Health Law. A description of the entire process, including the form to use, how the appeal works, and what to do if the appeal is denied is available at this link: health.ny.gov/professionals/patients/patient_rights/docs/you_and_your_health_records.htm

7 Glossary Advance Directives Advance directives are verbal or written instructions made by you before an incapacitating illness or injury (see page 22). Advance directives communicate that your wishes about your treatment be followed if you are too sick or unable to make decisions about your care. Advance directives include but are not limited to a health care proxy, a consent to a do-not-resuscitate (DNR) order recorded in your and a living will. Cardiopulmonary Resuscitation (CPR) CPR is a used to restart a patient’s heart and lungs when your breathing or circulation stops (see page 24). Diagnosis Related Groups (DRGs) The diagnosis related group (DRG) system categorizes the entire range of reasons people are hospitalized into about 600 groups to determine how much the hospital will be paid by your insurance. The DRG system is based on the average cost of treating a patient within the same age range, diagnosed with the same or similar condition and needing the same type of treatment. For example, one amount is paid for patients with pneumonia and a different amount for patients with a broken hip. It takes into account a hospital’s expenses, regional costs, inflation and patient needs. The New York State Department of Health has developed Medicaid and Workers Compensation/No Fault payments rates for each DRG within each hospital. This does not limit the number of days a patient may stay in the hospital. Your length of stay depends solely on your medical condition. (Note: Certain units and facilities do not use DRGs.) Discharge Notice A New York State hospital discharge notice should include information on your discharge date and how to appeal if you disagree with the notice. A discharge notice must be provided to all patients (except Medicare patients who receive a copy of an “Important Message from Medicare”) in writing 24 hours before they leave the hospital. Medicare patients must request a written discharge notice (“The Important Message from Medicare”) if they disagree with discharge. If requested, the notice must be provided. Once the notice is provided and if the Medicare patient disagrees with the notice, an appeal can be processed. Discharge Plan All patients (including Medicare patients) in New York State hospitals must receive a written discharge plan before they leave the hospital. This plan should describe the arrangements for any health care services you may need after you leave the hospital. The necessary services described in this plan must be secured or reasonably available before you leave the hospital. Discharge Planning Discharge planning is the process by which hospital staff work with you and your family or someone acting on your behalf to prepare and make arrangements for your care once you leave the hospital. This care may be self care, care by family members, home health assistance or admission to another health care facility. Discharge planning includes assessing and identifying what your needs will be when you leave the hospital and planning for appropriate care to meet those needs when you are discharged. A plan must be provided to you in writing before you leave the hospital. Discharge planning usually involves the patient, family members or the person you designate to act on your behalf, your doctor and a member of the hospital staff. Some hospitals have staff members who are called “discharge planners.” In other hospitals, a nurse or social worker may assist in discharge planning.

8 Do-Not-Resuscitate (DNR) Order At your request, a DNR order may be included in your medical chart. It instructs the medical staff not to try to revive you if your breathing or heartbeat has stopped. This means that doctors, nurses and other health care practitioners will not initiate such emergency procedures as mouth-to-mouth resuscitation, external chest compression, electric shock, insertion of a tube to open your airway, injection of into your heart or open chest. Under New York State law, all adult patients can request a DNR order verbally or in writing if two witnesses are present. In addition, the Health Care Proxy Law allows you to appoint someone to make decisions about DNR and other treatments if you become unable to do so. Health Care Proxy form New York State has a law that allows you to appoint someone you trust, for example, a family member or close friend as your Health Care Agent, to decide about your treatment if you lose the ability to decide for yourself. You may also use this form to indicate your wishes regarding organ donation in the event of your death (see page 29). Independent Professional Review Agents (IPRA) These review agents handle appeals for patients covered by Medicaid, private insurance or those without any insurance if they are having problems getting the care they will need after discharge from the hospital. For example, an IPRA would review the medical records of patients who are discharged before they are medically ready, and if an appropriate discharge plan has not been done or if appropriate services were not in place. Island Peer Review Organizations (IPRO) Island Peer Review Organization (IPRO) works with the New York State Department of Health to conduct the review of hospital care provided to people who are eligible for Medicaid. This is the agency Medicaid patients should contact if they think they are being discharged too soon from the hospital. Call toll-free at 1-800-648-4776, or 1-516-326-6131. Livanta This is the quality improvement organization contracted by the federal and state government to review the hospital’s care provided to Medicare patients in New York State. • This is the agency Medicare patients should contact if they think they are being discharged too soon from the hospital. Patients with dual Medicare & Medicaid coverage may call Livanta toll free at 1-866-815-5440. • If you have complaints about the quality of care you receive as a Medicare patient, call Livanta toll-free at 1-866-815-5440. • TTY users should call 1-866-868-2289. • Livanta provides translation services for all languages. Living Will A living will is a written document that expresses in advance your specific instructions and choices about various types of medical treatments and certain medical conditions. Living wills may be recognized as evidence of your wishes (if such wishes are expressed in a clear and convincing manner) if you are seriously ill and not able to communicate.

9 Managed Care Managed care refers to the way an individual’s (or family member’s) health care is organized and paid for. While health care maintenance organizations (HMOs) are the best known managed care plans, there are many other types. If you are enrolled in a managed care plan, your access to health care services is coordinated by the plan and/or physician. Therefore, you should understand how, when and where to access health care services, including hospital services, according to your plan’s rules and benefits. Read your plan’s enrollment information carefully and ask questions of your plan representative to be sure you understand your benefits, rights and responsibilities. Medicaid (Title XIX of the Social Security Act) Medicaid is a federal program, financed by federal, state and local governments, intended to provide access to health care services for the poor, specifically those who meet certain eligibility requirements such as income level. Medical Misconduct If you feel you have received poor or substandard care (incompetent, negligent or fraudulent care) from a doctor or physician assistant, you may file a report with the New York State Department of Health. Physicians and other health professionals are required by law to report any instance of suspected misconduct. Some examples of medical misconduct are: • practicing the profession fraudulently, or with gross incompetence or negligence; • practicing while impaired by alcohol, drugs, physical disability or mental disability; • being convicted of a crime; • refusing to provide medical services because of race, creed, color or ethnic origin; • guaranteeing that a cure will result from medical services; • failing to make available to the patient or another physician, upon a patient’s written request, copies of X-rays or medical records; • willfully making or filing a false report, or failing to file a report required by law or inducing another person to do so; • willfully harassing, abusing or intimidating a patient; and, • ordering excessive tests or treatment; • promoting the sale of services, goods, appliances or drugs in a manner that exploits the patient; • abandoning or neglecting a patient under and in need of immediate professional care. For additional information, NYS Education Law defines medical misconduct in Section 6531 at the following link: health.ny.gov/professionals/doctors/conduct/laws.htm Medicare (Title XVIII of the Social Security Act) Medicare is a federal program, administered by the federal government, which pays part of the costs of medical services for people aged 65 or older or who are disabled. Eligibility rests solely upon age or disability.

10 Medical Orders for Life-Sustaining Treatment (MOLST) Honoring patient preferences is a critical element in providing quality end-of-life care. To help physicians and other health care providers discuss and convey a patient’s wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatment, the Department of Health has approved a physician order form DOH-5003 Medical Orders for Life-Sustaining Treatment (MOLST), which can be used statewide by health care practitioners and facilities. MOLST is intended for patients with serious health conditions who: • want to avoid or receive any or all life-sustaining treatment; • reside in a long-term care facility or require long-term care services; and/or • might die within the next year. The form and additional information can be accessed through the following link: health.ny.gov/professionals/patients/patient_rights/molst/ Patient Representative The patient representative is a member of the hospital staff who serves as a link between the patient, family, physicians and other hospital staff. The patient representative should be available to answer questions about hospital procedures, help with special needs or concerns and help solve problems. The patient representative is familiar with all hospital services and will assist you. There is no charge for services rendered by the patient representative. Quality Improvement Organization (QIO) QIOs are the agencies responsible for ongoing review of the inpatient hospital care provided to people who are eligible for Medicare. In New York State, the QIO is Livanta (see page 9). Utilization Review Utilization review is a process where the need, appropriateness and effectiveness of care are evaluated. This is performed by a hospital utilization review (UR) committee, a Quality Improvement Organization (QIO) (see QIO), a public agency (health department, for example) or an independent organization.

11 Regulations and Information This section presents each document that the law requires you receive as an inpatient in a hospital in New York State.

Patients’ Rights Patients’ Bill of Rights ...... 13 An Important Message Regarding Your Rights as a Hospital Inpatient (for patients not covered by Medicare) ...... 14 Admission Notice for Medicare Patients ...... 16 Important Message from Medicare ...... 17

Deciding About Health Care: A Guide for Patients and Families ...... 21

Appointing Your Health Care Agent—New York State’s Proxy Law 29 Health Care Proxy form 33

Data Collection Letter from the New York State Department of Health (explains the SPARCS data collection system) ...... 35

Information that must be provided upon prebooking if you are a maternity patient: Maternity Information ...... 36

Domestic Violence: Notice for Prenatal and Maternity Patients 37 Domestic Violence: Victim’s Rights Notice 39

Parents’ Bill of Rights 41

Information that must be provided before you leave the hospital: • All patients must receive a written discharge plan. • Medicare patients receive a copy of the “Important Message From Medicare”. • All other patients must receive a hospital discharge notice.

If you have trouble understanding anything or have any questions about these materials, ask the hospital staff for an explanation. It is your right!

12 Patients’ Bill of Rights in a Hospital As a patient in a hospital in New York State, you have the right, consistent with law, to: (1) Understand and use these rights. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter. (2) Receive treatment without discrimination as to race, color, religion, sex, gender identity, national origin, disability, sexual orientation, age or source of payment. (3) Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints. (4) Receive emergency care if you need it. (5) Be informed of the name and position of the doctor who will be in charge of your care in the hospital. (6) Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation. (7) Identify a caregiver who will be included in your discharge planning and sharing of post-discharge care information or instruction. (8) Receive complete information about your diagnosis, treatment and prognosis. (9) Receive all the information that you need to give for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment. (10) Receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so. If you would like additional information, please ask for a copy of the pamphlet “Deciding About Health Care — A Guide for Patients and Families.” (11) Refuse treatment and be told what effect this may have on your health. (12) Refuse to take part in research. In deciding whether or not to participate, you have the right to a full explanation. (13) Privacy while in the hospital and confidentiality of all information and records regarding your care. (14) Participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. (15) Review your medical record without charge and, obtain a copy of your medical record for which the hospital can charge a reasonable fee. You cannot be denied a copy solely because you cannot afford to pay. (16) Receive an itemized bill and explanation of all charges. (17) View a list of the hospital’s standard charges for items and services and the health plans the hospital participates with. (18) Challenge an unexpected bill through the Independent Dispute Resolution process. (19) Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. If you are not satisfied with the hospital’s response, you can complain to the New York State Health Department. The hospital must provide you with the State Health Department telephone number. (20) Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors. (21) Make known your wishes in regard to anatomical gifts. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as a health care proxy, will, donor card, or other signed paper). The health care proxy is available from the hospital.

Public Health Law(PHL)2803 (1)(g)Patient’s Rights, 10NYCRR, 405.7,405.7(a)(1),405.7(c)

Department 1500 of Health 2/19 13 Important Message Regarding Your Rights as a Hospital Inpatient

Your Rights While a Hospital Patient You have the right to receive all of the hospital care that you need for the treatment of your illness or injury. Your discharge date is determined only by YOUR health care needs, not by your DRG category or your insurance. You have the right to be fully informed about decisions affecting your care and your insurance coverage. ASK QUESTIONS. You have the right to designate a representative to act on your behalf. You have the right to know about your medical condition. Talk to your doctor about your condition and your health care needs. If you have questions or concerns about hospital services, your discharge date or your discharge plan, consult your doctor or a hospital representative (such as the nurse, social worker or discharge planner). Before you are discharged you must receive a written DISCHARGE NOTICE and a written DISCHARGE PLAN. You and/or your representative have the right to be involved in your discharge planning. You have the right to appeal the written discharge plan or notice you receive from the hospital.

If You Think You are Being Asked to Leave the Hospital Too Soon Be sure you have received the written notice of discharge that the hospital must give you. You need this discharge notice in order to appeal. This notice will say whom to call and how to appeal. To avoid extra charges you must call to appeal no later than your planned discharge date. If you miss this time you may still appeal. However, you may have to pay for your continued stay in the hospital, if you lose your appeal.

Discharge Plans In addition to the right to appeal, you have the right to receive a written discharge plan that describes the arrangements for any future health care you may need after discharge. You may not be discharged until the services required in your written discharge plan are secured or determined by the hospital to be reasonably available. You also have the right to appeal this discharge plan.

14 Patients’ Rights* A general statement of your additional rights as a patient must be provided to you at this time.

For Assistance/Help The independent Professional Review Agent (IPRA) for your area and your insurance coverage is:

*This information is now included in this booklet. Patients are provided with a notice of their rights regarding admission and discharge. Medicare patients will be given the “Hospital Admission Notice for Medicare Patients”, and all other patients will be given “An Important Message Regarding Your Rights as a Hospital Inpatient.” Public Health Law 2803 (1) (g) Discharge Review 10NYCRR, 405.9 (b) (14) (i) and 405.9 (b) (14) (ii) Patients (or appointed personal representatives) are provided with a written discharge notice and a copy of a discharge plan. Patients (or their representatives) must be given the opportunity to sign the documents and receive a copy of the signed documents. 10NYCRR, 405.9 (g) (1) and 405.9 (g) (3) (i)

15 Admission Notice for Medicare Patients You have the following rights under the New York State law: Before you are discharged, you must receive a written Discharge Plan. You or your representative have the right to be involved in your discharge planning. Your written Discharge Plan must describe the arrangements for any future health care that you may need after discharge. You may not be discharged until the services required in your written Discharge Plan are secured or determined to be reasonably available. If you do not agree with the Discharge Plan or believe the services are not reasonably available, you may call the New York State Health Department to investigate your complaint and the safety of your discharge. The hospital must provide you with the State Health Department’s telephone number if you ask for it. For important information about your rights as a Medicare patient, see “Important Message from Medicare,” on the following page.

Patients are provided with a notice of their rights regarding admission and discharge. Medicare patients will be given “Hospital Admission Notice for Medicare Patients”, and all other patients will be given “An Important Message Regarding Your Rights as a Hospital Inpatient” Public Health Law 2803 (1) (g) Discharge Review 10NYCRR 405.9 (b) (14) (i) and 405.9 (b) (14) (ii)

16 Important Message from Medicare About Your Rights

Patient Name: DEPARTMENT OF HEALTH & HUMAN SERVICES Patient ID Number: Centers for Medicare & Medicaid Services Physician: OMB Approval No. 0938-0692 AN IMPORTANT MESSAGE FROM MEDICARE ABOUT YOUR RIGHTS As A Hospital Inpatient, You Have The Right To: • Receive Medicare covered services. This includes medically necessary hospital services and services you may need after you are discharged, if ordered by your doctor. You have a right to know about these services, who will pay for them, and where you can get them. • Be involved in any decisions about your hospital stay, and know who will pay for it. • Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here: Name of QIO Livanta Telephone Number of QIO 1-866-815-5440 Your Medicare Discharge Rights Planning For Your Discharge: During your hospital stay, the hospital staff will be working with you to prepare for your safe discharge and arrange for services you may need after you leave the hospital. When you no longer need inpatient hospital care, your doctor or the hospital staff will inform you of your planned discharge date. If you think you are being discharged too soon: • You can talk to the hospital staff, your doctor and your managed care plan (if you belong to one) about your concerns. • You also have the right to an appeal, that is, a review of your case by a Quality Improvement Organization (QIO). The QIO is an outside reviewer hired by Medicare to look at your case to decide whether you are ready to leave the hospital.

o If you want to appeal, you must contact the QIO no later than your planned discharge date and before you leave the hospital.

o If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles). • If you do not appeal, but decide to stay in the hospital past your planned discharge date, you may have to pay for any services you receive after that date. • Step by step instructions for calling the QIO and filing an appeal are on page 2. To speak with someone at the hospital about this notice, call .

Please sign and date here to show you received this notice and understand your rights. Signature of Patient or Representative Date/Time

Form CMS-R-193 (approved 07/10)

17 Steps To Appeal Your Discharge • Step 1: You must contact the QIO no later than your planned discharge date and before you leave the hospital. If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles). o Here is the contact information for the QIO: Name of QIO (in bold) Livanta Telephone Number of QIO 1-866-815-5440 o You can file a request for an appeal any day of the week. Once you speak to someone or leave a message, your appeal has begun. o Ask the hospital if you need help contacting the QIO. o The name of this hospital is : Hospital Name Provider ID Number

• Step 2: You will receive a detailed notice from the hospital or your Medicare Advantage or other Medicare managed care plan (if you belong to one) that explains the reasons they think you are ready to be discharged. • Step 3: The QIO will ask for your opinion. You or your representative need to be available to speak with the QIO, if requested. You or your representative may give the QIO a written statement, but you are not required to do so. • Step 4: The QIO will review your medical records and other important information about your case. • Step 5: The QIO will notify you of its decision within 1 day after it receives all necessary information. o If the QIO finds that you are not ready to be discharged, Medicare will continue to cover your hospital services. o If the QIO finds you are ready to be discharged, Medicare will continue to cover your services until noon of the day after the QIO notifies you of its decision.

If You Miss The Deadline To Appeal, You Have Other Appeal Rights: • You can still ask the QIO or your plan (if you belong to one) for a review of your case: o If you have Original Medicare: Call the QIO listed above. o If you belong to a Medicare Advantage Plan or other Medicare managed care plan: Call your plan. • If you stay in the hospital, the hospital may charge you for any services you receive after your planned discharge date.

For more information, call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048.

Additional Information:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 0692. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

18 Patient Name: DEPARTMENT OF HEALTH & HUMAN SERVICES Patient ID Number: Centers for Medicare & Medicaid Services Physician: OMB Approval No. 0938-0692 Notice Instructions: THE IMPORTANT MESSAGE FROM MEDICARE Completing The Notice Page 1 of the Important Message from Medicare

A. Header Hospitals must display “Department of Health & Human Services, Centers for Medicare & Medicaid Services” and the OMB number. The following blanks must be completed by the hospital. Information inserted by hospitals in the blank spaces on the IM may be typed or legibly hand-written in 12-point font or the equivalent. Hospitals may also use a patient label that includes the following information: Patient Name: Fill in the patient’s full name. Patient ID number: Fill in an ID number that identifies this patient. This number should not be, nor should it contain, the social security number. Physician: Fill in the name of the patient’s physician.

B. Body of the Notice Bullet number 3 – Report any concerns you have about the quality of care you receive to the Quality Improvement Organization (QIO) listed here . Hospitals may preprint or otherwise insert the name and telephone number (including TTY) of the QIO. To speak with someone at the hospital about this notice call: Fill in a telephone number at the hospital for the patient or representative to call with questions about the notice. Preferably, a contact name should also be included. Patient or Representative Signature: Have the patient or representative sign the notice to indicate that he or she has received it and understands its contents. Date/Time: Have the patient or representative place the date and time that he or she signed the notice.

Page 2 of the Important Message from Medicare First sub-bullet – Insert name and telephone number of QIO in bold: Insert name and telephone number (including TTY), in bold, of the Quality Improvement Organization that performs reviews for the hospital. Second sub-bullet – The name of this hospital is: Insert/preprint the name of the hospital, including the Medicare provider ID number (not the telephone number). Additional Information: Hospitals may use this section for additional documentation, including, for example, obtaining beneficiary initials, date, and time to document delivery of the follow-up copy of the IM, or documentation of refusals.

19 20 Deciding About Health Care A GUIDE FOR PATIENTS AND FAMILIES

New York State Department of Health

21 Introduction What if it’s unclear whether or not a patient has decision-making capacity? Who decides Who should read this guide? whether or not the patient has capacity? This guide is for New York State patients and Health care workers will assume patients have for those who will make health care decisions decision-making capacity, unless a court has for patients. It contains information about appointed a legal guardian to decide about surrogate decision-making in hospitals and health care. A doctor will examine the patient if nursing homes. It also covers DNR orders there is good reason to believe the patient lacks in a health care facility, or in the community. capacity. A doctor must make the determination Because this guide is about health care that a patient lacks the ability to make health decision-making, the word “patient” is used to care decisions. Another person will make health refer to anyone receiving medical care. This care decisions for the patient only after the includes a nursing home resident. This guide patient’s doctor makes this determination. does not include the special rules for health Do family members always make health care care decisions made by legal guardians of decisions whenever patients lack decision- persons with developmental disabilities. making capacity? Can the patient or other decision maker find No. Sometimes patients have already made out about the patient’s medical condition and a decision about a procedure or treatment proposed treatment? before they lose the ability to decide. For Yes. Patients or other decision makers have example, a patient can consent to that a right to be fully informed by a doctor about involves general before receiving their medical condition and the doctor’s anesthesia, which would cause them to lose proposed treatment. Patients must give the ability to decide. Other times, a healthy informed consent before any non-emergency person may suddenly lose capacity. In this treatment or procedure. Informed consent case, health care may need to be given right means that after information is given about away without consent. For example, a person the benefits and risks of treatment (as well as may be knocked unconscious during an alternatives to the treatment) permission is accident. Health care providers will provide given to go ahead with the treatment. emergency treatment without consent unless they know that a decision has already been Adult Patients Who Have the made to refuse emergency treatment. Ability to Make Informed Decisions Advance Directives/ Do adult patients have a right to make their Health Care Proxies own health care decisions? Yes. Adult patients have the right to make What is an advance directive? treatment decisions for themselves as long as Advance directives are written instructions they have decision-making capacity. about health care treatment made by adult patients before they lose decision-making What is “decision-making capacity”? capacity. In New York State, the best way to “Decision-making capacity” is the ability to protect your treatment wishes and concerns is understand and appreciate the nature and to appoint someone you trust to decide about consequences of proposed health care. treatment if you become unable to decide for This includes the benefits and risks of (and yourself. By filling out a form called a health alternatives to) proposed health care. It also care proxy, this person becomes your “health includes the ability to reach an informed care agent.” decision. Before appointing a health care agent, make sure the person is willing to act as your agent.

22 Discuss with your agent what types resident may not verbally make a decision to of treatments you would or would not want withhold or withdraw life-sustaining treatment if you were in the hospital and had a unless two adults witness the decision. One of life-threatening illness or injury. Make sure the adults must be a health care practitioner your health care agent knows your wishes at the facility. If a patient does not now have about artificial nutrition and hydration (being capacity to make a decision (but made a fed through a feeding tube or IV line). You can decision in the past about the proposed get more information about health care proxies health care), the hospital or nursing home at: https://www.health.ny.gov/professionals/ will act based on the patient’s previously patients/health_care_proxy/ made decision. This is true unless something Some patients also express specific occurs that the patient did not expect and the instructions and choices about medical decision no longer makes sense. treatments in writing. A written statement can How are health care decisions made for a be included in a health care proxy, or it can be hospital patient or nursing home resident who in a separate document. Some people refer to does not have capacity? this type of advance directive as a “living will.” If the patient has a health care proxy, the How do health care agents make decisions health care agent named in the proxy makes under a health care proxy? decisions. If a patient does not have a health Health care agents make decisions just as care proxy, a legal guardian (or the person if the health care agent were the patient. highest in priority from the surrogate list, The health care agent makes health care known as “the surrogate”) makes decisions. decisions according to the patient’s wishes, What is the surrogate list? including decisions to withhold or withdraw Below is the surrogate list. The person who life-sustaining treatment. If the patient’s wishes is highest in priority is listed at the top. The are not reasonably known, health care agents person with the lowest priority is at the bottom. make health care decisions in accordance with the patient’s best interests. • The spouse, if not legally separated from the patient, or the domestic partner; Can a health care agent decide to withhold • A son or daughter 18 or older; or withdraw artificial nutrition or hydration (through a feeding tube or an IV line)? • A parent; Health care agents can only make decisions • A brother or sister 18 or older; and to withhold or withdraw artificial nutrition and • A close friend. hydration under the health care proxy if they What is a “domestic partner”? know the patient’s wishes about the treatment. A “domestic partner” is a person who: But, the health care agent may also be able to make this type of decision in a hospital or • has entered into a formal domestic nursing home as a surrogate from the surrogate partnership recognized by a local, state or list set forth in law. national government. Or, this person has registered as a domestic Health Care Decision-Making partner with a registry maintained by the government or an employer; or, this person in Hospitals and Nursing Homes • is covered as a domestic partner under How do adult patients with decision-making the same employment benefits or health capacity make decisions in hospitals and insurance; or, this person nursing homes? • shares a mutual intent to be a domestic Patients may express decisions verbally or partner with the patient, considering all the in writing. A hospital patient or nursing home facts and circumstances, such as:

23 • They live together. Decisions to Withhold or Withdraw • They depend on each other for support. Life-Sustaining Treatment in • They share ownership (or a lease) of their Hospitals and Nursing Homes home or other property. • They share income or expenses. What is “life-sustaining treatment”? • They are raising children together. “Life-sustaining treatment” means that the • They plan on getting married or becoming attending doctor believes the patient will die formal domestic partners. within a relatively short time if the patient • They have been together for a long time. does not get the medical treatment or procedure. CPR is always considered to be Who cannot be a domestic partner? life-sustaining treatment. • A parent, grandparent, child, grandchild, brother, sister, uncle, aunt, nephew or niece What is CPR? of the patient or the patient’s spouse. CPR (cardiopulmonary resuscitation) refers to • A person who is younger than 18. medical procedures that try to restart a patient’s heart or breathing when the patient’s heart Who qualifies as a “close friend”? stops and/or the patient stops breathing. CPR A “close friend” is any person, 18 or older, who may begin with something like mouth-to-mouth is a friend or relative of the patient. This person resuscitation and forceful pressure on the must have maintained regular contact with the chest to try to restart the heart. This may not patient; be familiar with the patient’s activities, work, so CPR may also involve electric shock health, and religious or moral beliefs; and (defibrillation); insertion of a tube down the present a signed statement to that effect to the throat into the windpipe (intubation); and placing attending doctor. the patient on a breathing machine (ventilator). What if a surrogate highest in priority is not What is a decision to withhold or withdraw available to make the decision? life-sustaining treatment? If this happens, the next available surrogate A decision to withhold life-sustaining treatment who is highest in priority makes the decision. is deciding to refuse a treatment before What if a surrogate highest in priority is unable it is provided. A decision to withdraw life- or unwilling to make the decision? sustaining treatment is deciding to refuse treatment already being provided. Every adult In this case, another person from the surrogate patient has the right to refuse and list will decide. The surrogate highest in priority treatment after being fully informed of (and may designate any other person on the list understanding) the probable consequences of to be surrogate, as long as no one higher in such actions. priority than the designated person objects. Can patients or other decision makers change their minds after they make a treatment decision? Yes. Decisions may be revoked after they are made by telling staff at the hospital or nursing home.

24 How would a hospital or a nursing home carry Only a doctor can sign a DNR order. A DNR out a decision to withhold or withdraw life- order instructs health care professionals not sustaining treatment? to provide CPR for patients who want to allow The doctor might direct staff not to provide, natural death to occur if their heart stops or to stop providing, certain , and/or if they stop breathing. For example, a treatments or procedures. This may result patient who is expecting to die from a terminal in the patient dying within a relatively short illness may want a DNR order. time. For example, the doctor might order When successful, CPR restores heartbeat and that a ventilator, which is enabling a patient to breathing. The success of CPR depends on breathe, be turned off. the patient’s overall medical condition. Age In order to withhold life-sustaining treatment, alone does not determine whether CPR will be the doctor might issue a medical order such successful. But illnesses and frailties that go as a: along with age often make CPR less effective. When patients are seriously ill, CPR may not • Do Not Resuscitate (DNR) Order: this means work or it may only partially work. This might do not attempt CPR when the patient’s heart leave the patient brain-damaged or in a worse stops and/or the patient stops breathing. medical state than before his or her heart • Do Not Intubate (DNI) Order: this means do stopped. After CPR (depending on the patient’s not place a tube down the patient’s throat or medical condition), the patient may be able to connect the patient to a breathing machine be kept alive only on a breathing machine. (ventilator). Does a DNR order affect other treatment? A decision could also be made to stop (or not to start) artificial nutrition and hydration No. A DNR order is only a decision about through a feeding tube or an IV. This means CPR – chest compression, intubation and the facility will not give the patient liquid food mechanical ventilation – and does not relate to or fluids through a tube inserted in the stomach any other treatment. Do not resuscitate does – or by a tube called a catheter inserted into not mean do not treat. the patient’s veins. Patients will always be What happens if the patient is transferred offered food to eat and fluids to drink by mouth from the hospital or nursing home to another if they are able to eat and drink. hospital or nursing home? Other kinds of decisions to limit medicines, Medical orders, including a DNR order, will treatments or procedures could also be continue until a health care practitioner followed (for example, stopping dialysis). examines the patient. If the doctor at the new Will a hospital or a nursing home ever withhold facility decides to cancel the medical order, all treatment? the patient or other decision maker will be told and he or she can ask that the order be No. Even if a patient has a DNR order or other entered again. medical order to withhold life-sustaining treatment, the patient should receive medical care and treatment to relieve pain and other Decision-Making Standards for symptoms and to reduce suffering. Comfort Legal Guardians and Surrogates care, also known as palliative care, should be in Hospitals and Nursing Homes available to all patients who need it. How are health care decisions made by When should a patient get a DNR order? surrogate decision makers, including Any adult with decision-making capacity may legal guardians? request a DNR order. However, patients and families must consult with a doctor about their The surrogate must make health care diagnosis and the likely outcome of CPR. decisions in accordance with the patient’s wishes, including the patient’s religious and

25 • Treatment would be an extraordinary burden to the patient and: • the patient has an illness or injury which can be expected to cause death within six months, whether or not treatment is provided; or • the patient is permanently unconscious; or • The provision of treatment would involve such pain, suffering or other burden that it would reasonably be deemed inhumane or extraordinarily burdensome under the circumstances and the patient has an irreversible or incurable condition. In a nursing home, an ethics review committee must also agree to decisions (other than DNR) based on this bullet-point. In a hospital, the attending doctor or the ethics review committee must agree to a decision moral beliefs. If the patient’s wishes are not to withhold or withdraw artificial nutrition reasonably known, the surrogate makes and hydration based on this bullet-point. decisions according to the patient’s “best How are decisions about life-sustaining interests.” To figure out what is in the “best treatment made for minors in a hospital or interests” of the patient, the surrogate must nursing home? consider: the dignity and uniqueness of every person; the possibility of preserving The parent or guardian of a patient under the patient’s life and preserving or improving 18 makes decisions about life-sustaining the patient’s health; relief of the patient’s treatment in accordance with the minor’s suffering; and any other concerns and values best interests. They take into account the a person in the patient’s circumstances would minor’s wishes as appropriate under the wish to consider. In all cases, what matters is circumstances. For a decision to withhold or the patient’s wishes and best interests, not withdraw life-sustaining treatment, the minor the surrogate’s. Health care decisions should patient must also consent if he or she has be made on an individual basis for each decision-making capacity. It is assumed that patient. Again, decisions must be consistent an unmarried minor lacks decision-making with the patient’s values, as well as religious capacity unless a doctor determines that the and moral beliefs. patient has the capacity to decide about life- sustaining treatment. Minors who are married Do surrogates always have authority to consent make their own decisions, the same as adults. to needed treatments? What if an unmarried minor patient has Yes. decision-making capacity and he or she is a Do surrogates always have authority to parent? What if he or she is 16 or older and make decisions to withhold or withdraw life- living independently from his or her parents sustaining treatment? or guardian? No. A legal guardian or a surrogate in a Such minors can make decisions to withhold or hospital or nursing home may decide to refuse withdraw life-sustaining treatment on their own life-sustaining treatment for a patient only in if the attending doctor and the ethics review the following circumstances: committee agree.

26 Resolving Disputes in Hospitals and Nursing Homes What if there are two or more persons highest in priority and they cannot agree? For example, what if the adult children are highest in priority and they disagree with one another? In this case, the hospital or nursing home staff can try to resolve the dispute by informal means. For example, more doctors, social workers or clergy could discuss the decision. Also, every hospital and nursing home must have an ethics review committee. The case may be referred to the ethics review committee for advice, a recommendation, and assistance in resolving the dispute. The hospital or nursing home must follow the decision of the surrogate that is based on the patient’s wishes, if they are known. If the agree with the decision in the following patient’s wishes are not reasonably known, three situations: the hospital or nursing home must follow the • A surrogate decides to withhold or withdraw decision that is in the patient’s best interests. life-sustaining treatment (other than CPR) What if a person connected with the case from a patient in a nursing home. The does not agree with the surrogate’s treatment patient is not expected to die within six decision? This could be the patient, a health months and is not permanently unconscious. care worker treating the patient in the hospital In this situation, the ethics review committee or nursing home or someone lower in priority must agree to the following. The patient on the surrogate list. has a condition that can’t be reversed or Again, the hospital or nursing home staff can cured. Also, the provision of life-sustaining try to resolve the dispute by informal means. treatment would involve such pain, suffering If that is not successful, the person who or other burden that it would reasonably disagrees could request help from the ethics be deemed inhumane or extraordinarily review committee. The person challenging burdensome under the circumstances. the decision maker can ask that the ethics • A surrogate decides to withhold or review committee try to resolve the dispute. withdraw artificial nutrition and hydration This person could present information and from a patient in a hospital. The attending opinions to the committee. The ethics review doctor objects. The patient is not committee can provide advice and make a expected to die within six months and recommendation, and can provide assistance is not permanently unconscious. In this in resolving the dispute. situation, the ethics review committee Are the recommendations and advice of the must agree to the following. The patient ethics review committee binding? has a condition that can’t be reversed or cured. Also, artificial nutrition and hydration No, the recommendations and advice of the would involve such pain, suffering or other ethics review committee are advisory and non- burden that it would reasonably be deemed binding, except for three very specific types of inhumane or extraordinarily burdensome decisions. The ethics review committee must under the circumstances.

27 • In a hospital or nursing home, an ethics review committee must approve the DNR Orders Outside the Hospital decision of an unmarried, emancipated or Nursing Home minor to withhold or withdraw life-sustaining If a patient is not in a hospital or nursing home, treatment without the consent of a parent or how can the patient get a DNR order or guardian. DNI order? • A physician decides to admit into hospice The patient’s doctor can write a DNR order on a patient who lacks capacity and who a standard form that has been approved by the does not have a health care proxy or New York State Department of Health: DOH- surrogate. The committee must also 3474 (Nonhospital Order Not to Resuscitate). review the hospice plan of care, which can A doctor can also sign a nonhospital DNI order include the withholding or withdrawal of in addition to the nonhospital DNR order using life-sustaining treatment if the standards the DOH-5003 form called MOLST (Medical are met for surrogate decision about such Orders for Life-Sustaining Treatment). EMS, treatment. home care agencies and hospices must honor In these three situations, life-sustaining these orders. treatment will not be withheld or withdrawn If the patient is at home with a nonhospital unless the ethics review committee approves. DNR order, or MOLST orders, what happens if a What does it mean when the recommendations family member or friend calls an ambulance? and advice of the ethics review committee are If the patient has a nonhospital DNR order and advisory and non-binding? it is shown to emergency personnel, they will not try to resuscitate the patient or take the This means that the surrogate highest in patient to a hospital emergency room for CPR. priority can make a legal health care decision. They may still take the patient to the hospital He or she can do this even if another person for other needed care, including comfort care lower in priority on the surrogate list or others to relieve pain and reduce suffering. continue to disagree with the surrogate decision maker. What happens to a DNR order issued in the hospital or nursing home if the patient is What if the hospital or nursing home has a transferred from the hospital or nursing home policy based on religious or moral beliefs that to home care? prevents the facility from honoring a health care decision? The orders issued for the patient in a hospital or nursing home may not apply at home. The When possible, the facility must inform patients patient or other decision maker must get a or family members of this policy before or at nonhospital DNR order on the DOH-3474 form admission. When the decision is made, the or the DOH-5003 MOLST form. If the patient facility must cooperate in transferring the leaves the hospital or nursing home without a patient to another facility that is reasonably nonhospital DNR order, it can be issued by a accessible and willing to honor the decision. doctor at home. Meanwhile, the facility must honor the decision, unless a court rules otherwise. If the decision goes against one health care practitioner’s religious or moral beliefs, the patient must be promptly put under the care of another health care practitioner.

Department of Health 1503 2/18

28 Health Care Proxy Appointing Your Health Care Agent in New York State The New York Health Care Proxy Law allows you to appoint someone you trust — for example, a family member or close friend – to make health care decisions for you if you lose the ability to make decisions yourself. By appointing a health care agent, you can make sure that health care providers follow your wishes. Your agent can also decide how your wishes apply as your medical condition changes. Hospitals, doctors and other health care providers must follow your agent’s decisions as if they were your own. You may give the person you select as your health care agent as little or as much authority as you want. You may allow your agent to make all health care decisions or only certain ones. You may also give your agent instructions that he or she has to follow. This form can also be used to document your wishes or instructions with regard to organ and/or tissue donation.

29 About the Health Care Proxy Form This is an important legal document. Before signing, you should understand the following facts: 1. This form gives the person you choose as your agent the authority to make all health care decisions for you, including the decision to remove or provide life-sustaining treatment, unless you say otherwise in this form. “Health care” means any treatment, service or procedure to diagnose or treat your physical or mental condition. 2. Unless your agent reasonably knows your wishes about artificial nutrition and hydration (nourishment and water provided by a feeding tube or intravenous line), he or she will not be allowed to refuse or consent to those measures for you. 3. Your agent will start making decisions for you when your doctor determines that you are not able to make health care decisions for yourself. 4. You may write on this form examples of the types of treatments that you would not desire and/ or those treatments that you want to make sure you receive. The instructions may be used to limit the decision-making power of the agent. Your agent must follow your instructions when making decisions for you. 5. You do not need a lawyer to fill out this form. 6. You may choose any adult (18 years of age or older), including a family member or close friend, to be your agent. If you select a doctor as your agent, he or she will have to choose between acting as your agent or as your attending doctor because a doctor cannot do both at the same time. Also, if you are a patient or resident of a hospital, nursing home or mental hygiene facility, there are special restrictions about naming someone who works for that facility as your agent. Ask staff at the facility to explain those restrictions. 7. Before appointing someone as your health care agent, discuss it with him or her to make sure that he or she is willing to act as your agent. Tell the person you choose that he or she will be your health care agent. Discuss your health care wishes and this form with your agent. Be sure to give him or her a signed copy. Your agent cannot be sued for health care decisions made in good faith. 8. If you have named your spouse as your health care agent and you later become divorced or legally separated, your former spouse can no longer be your agent by law, unless you state otherwise. If you would like your former spouse to remain your agent, you may note this on your current form and date it or complete a new form naming your former spouse. 9. Even though you have signed this form, you have the right to make health care decisions for yourself as long as you are able to do so, and treatment cannot be given to you or stopped if you object, nor will your agent have any power to object. 10. You may cancel the authority given to your agent by telling him or her or your orally or in writing. 11. Appointing a health care agent is voluntary. No one can require you to appoint one. 12. You may express your wishes or instructions regarding organ and/or tissue donation on this form.

30 Frequently Asked Questions Why should I choose a health care agent? If you become unable, even temporarily, to make health care decisions, someone else must decide for you. Health care providers often look to family members for guidance. Family members may express what they think your wishes are related to a particular treatment. Appointing an agent lets you control your medical treatment by: • allowing your agent to make health care decisions on your behalf as you would want them decided; • choosing one person to make health care decisions because you think that person would make the best decisions; • choosing one person to avoid conflict or confusion among family members and/or significant others. You may also appoint an alternate agent to take over if your first choice cannot make decisions for you. Who can be a health care agent? Anyone 18 years of age or older can be a health care agent. The person you are appointing as your agent or your alternate agent cannot sign as a witness on your Health Care Proxy form. How do I appoint a health care agent? All competent adults, 18 years of age or older, can appoint a health care agent by signing a form called a Health Care Proxy. You don’t need a lawyer or a notary, just two adult witnesses. Your agent cannot sign as a witness. You can use the form printed here, but you don’t have to use this form. When would my health care agent begin to make health care decisions for me? Your health care agent would begin to make health care decisions after your doctor decides that you are not able to make your own health care decisions. As long as you are able to make health care decisions for yourself, you will have the right to do so. What decisions can my health care agent make? Unless you limit your health care agent’s authority, your agent will be able to make any health care decision that you could have made if you were able to decide for yourself. Your agent can agree that you should receive treatment, choose among different treatments and decide that treatments should not be provided, in accordance with your wishes and interests. However, your agent can only make decisions about artificial nutrition and hydration (nourishment and water provided by feeding tube or intravenous line) if he or she knows your wishes from what you have said or what you have written. The Health Care Proxy form does not give your agent the power to make non- health care decisions for you, such as financial decisions. Why do I need to appoint a health care agent if I’m young and healthy? Appointing a health care agent is a good idea even though you are not elderly or terminally ill. A health care agent can act on your behalf if you become even temporarily unable to make your own health care decisions (such as might occur if you are under general anesthesia or have become comatose because of an accident). When you again become able to make your own health care decisions, your health care agent will no longer be authorized to act. How will my health care agent make decisions? Your agent must follow your wishes, as well as your moral and religious beliefs. You may write instructions on your Health Care Proxy form or simply discuss them with your agent.

31 Frequently Asked Questions, continued

How will my health care agent know my wishes? Having an open and frank discussion about your wishes with your health care agent will put him or her in a better position to serve your interests. If your agent does not know your wishes or beliefs, your agent is legally required to act in your best interest. Because this is a major responsibility for the person you appoint as your health care agent, you should have a discussion with the person about what types of treatments you would or would not want under different types of circumstances, such as: • whether you would want life support initiated/continued/removed if you are in a permanent ; • whether you would want treatments initiated/continued/removed if you have a terminal illness; • whether you would want artificial nutrition and hydration initiated/withheld or continued or withdrawn and under what types of circumstances. Can my health care agent overrule my wishes or prior treatment instructions? No. Your agent is obligated to make decisions based on your wishes. If you clearly expressed particular wishes, or gave particular treatment instructions, your agent has a duty to follow those wishes or instructions unless he or she has a good faith basis for believing that your wishes changed or do not apply to the circumstances. Who will pay attention to my agent? All hospitals, nursing homes, doctors and other health care providers are legally required to provide your health care agent with the same information that would be provided to you and to honor the decisions by your agent as if they were made by you. If a hospital or nursing home objects to some treatment options (such as removing certain treatment) they must tell you or your agent BEFORE or upon admission, if reasonably possible. What if my health care agent is not available when decisions must be made? You may appoint an alternate agent to decide for you if your health care agent is unavailable, unable or unwilling to act when decisions must be made. Otherwise, health care providers will make health care decisions for you that follow instructions you gave while you were still able to do so. Any instructions that you write on your Health Care Proxy form will guide health care providers under these circumstances. What if I change my mind? It is easy to cancel your Health Care Proxy, to change the person you have chosen as your health care agent or to change any instructions or limitations you have included on the form. Simply fill out a new form. In addition, you may indicate that your Health Care Proxy expires on a specified date or if certain events occur. Otherwise, the Health Care Proxy will be valid indefinitely. If you choose your spouse as your health care agent or as your alternate, and you get divorced or legally separated, the appointment is automatically cancelled. However, if you would like your former spouse to remain your agent, you may note this on your current form and date it or complete a new form naming your former spouse. Can my health care agent be legally liable for decisions made on my behalf? No. Your health care agent will not be liable for health care decisions made in good faith on your behalf. Also, he or she cannot be held liable for costs of your care, just because he or she is your agent.

32 Frequently Asked Questions, continued

Is a Health Care Proxy the same as a living will? No. A living will is a document that provides specific instructions about health care decisions. You may put such instructions on your Health Care Proxy form. The Health Care Proxy allows you to choose someone you trust to make health care decisions on your behalf. Unlike a living will, a Health Care Proxy does not require that you decide in advance decisions that may arise. Instead, your health care agent can interpret your wishes as medical circumstances change and can make decisions you could not have known would have to be made. Where should I keep my Health Care Proxy form after it is signed? Give a copy to your agent, your doctor, your attorney and any other family members or close friends you want. Keep a copy in your wallet or purse or with other important papers, but not in a location where no one can access it, like a safe deposit box. Bring a copy if you are admitted to the hospital, even for minor surgery, or if you undergo . May I use the Health Care Proxy form to express my wishes about organ and/or tissue donation? Yes. Use the optional organ and tissue donation section on the Health Care Proxy form and be sure to have the section witnessed by two people. You may specify that your organs and/or tissues be used for transplantation, research or educational purposes. Any limitation(s) associated with your wishes should be noted in this section of the proxy. Failure to include your wishes and instructions on your Health Care Proxy form will not be taken to mean that you do not want to be an organ and/or tissue donor. Can my health care agent make decisions for me about organ and/or tissue donation? Yes. As of August 26, 2009, your health care agent is authorized to make decisions after your death, but only those regarding organ and/or tissue donation. Your health care agent must make such decisions as noted on your Health Care Proxy form. Who can consent to a donation if I choose not to state my wishes at this time? It is important to note your wishes about organ and/or tissue donation to your health care agent, the person designated as your decedent’s agent, if one has been appointed, and your family members. New York Law provides a list of individuals who are authorized to consent to organ and/ or tissue donation on your behalf. They are listed in order of priority: your health care agent; your decedent’s agent; your spouse, if you are not legally separated, or your domestic partner; a son or daughter 18 years of age or older; either of your parents; a brother or sister 18 years of age or older; a guardian appointed by a court prior to the donor’s death; or another person authorized to dispose of the body.

33 Health Care Proxy Form Instructions Item (1) I have discussed with my agent my wishes Write the name, home address and telephone about______and I want my agent number of the person you are selecting as to make all decisions about these measures. your agent. Examples of medical treatments about which Item (2) you may wish to give your agent special If you want to appoint an alternate agent, instructions are listed below. This is not a write the name, home address and telephone complete list: number of the person you are selecting as • artificial respiration your alternate agent. • artificial nutrition and hydration (nourishment and water provided by Item (3) Your Health Care Proxy will remain valid feeding tube) indefinitely unless you set an expiration date • cardiopulmonary resuscitation (CPR) or condition for its expiration. This section is • antipsychotic medication optional and should be filled in only if you want • electric shock your Health Care Proxy to expire. • antibiotics • surgical procedures Item (4) • dialysis If you have special instructions for your agent, • transplantation write them here. Also, if you wish to limit your • blood transfusions agent’s authority in any way, you may say so • abortion here or discuss them with your health care • sterilization agent. If you do not state any limitations, your agent will be allowed to make all health care Item (5) decisions that you could have made, including You must date and sign this Health Care the decision to consent to or refuse life- Proxy form. If you are unable to sign yourself, sustaining treatment. you may direct someone else to sign in your presence. Be sure to include your address. If you want to give your agent broad authority, you may do so right on the form. Simply write: I Item (6) have discussed my wishes with my health care You may state wishes or instructions about agent and alternate and they know my wishes organ and/or tissue donation on this form. New including those about artificial nutrition and York law does provide for certain individuals hydration. in order of priority to consent to an organ and/or tissue donation on your behalf: your If you wish to make more specific instructions, health care agent, your decedent’s agent, your you could say: spouse, if you are not legally separated, or If I become terminally ill, I do/don’t want to your domestic partner, a son or daughter 18 receive the following types of treatments.... years of age or older, either of your parents, a brother or sister 18 years of age or older, If I am in a coma or have little conscious a guardian appointed by a court prior to the understanding, with no hope of recovery, donor’s death. then I do/don’t want the following types of treatments:.... Item (7) Two witnesses 18 years of age or older must If I have brain damage or a brain sign this Health Care Proxy form. The person that makes me unable to recognize people who is appointed your agent or alternate agent or speak and there is no hope that my cannot sign as a witness. condition will improve, I do/don’t want the following types of treatments:....

34 Health Care Proxy (1) I, hereby appoint (name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise. This proxy shall take effect only when and if I become unable to make my own health care decisions.

(2) Optional: Alternate Agent If the person I appoint is unable, unwilling or unavailable to act as my health care agent, I hereby appoint (name, home address and telephone number)

as my health care agent to make any and all health care decisions for me, except to the extent that I state otherwise.

(3) Unless I revoke it or state an expiration date or circumstances under which it will expire, this proxy shall remain in effect indefinitely.Optional: ( If you want this proxy to expire, state the date or conditions here.) This proxy shall expire (specify date or conditions):

(4) Optional: I direct my health care agent to make health care decisions according to my wishes and limitations, as he or she knows or as stated below. (If you want to limit your agent’s authority to make health care decisions for you or to give specific instructions, you may state your wishes or limitations here.) I direct my health care agent to make health care decisions in accordance with the following limitations and/or instructions (attach additional pages as necessary):

In order for your agent to make health care decisions for you about artificial nutrition and hydration (nourishment and water provided by feeding tube and intravenous line), your agent must reasonably know your wishes. You can either tell your agent what your wishes are or include them in this section. See instructions for sample language that you could use if you choose to include your wishes on this form, including your wishes about artificial nutrition and hydration.

35 (5) Your Identification (please print) Your Name Your Signature Date Your Address

(6) Optional: Organ and/or Tissue Donation I hereby make an anatomical gift, to be effective upon my death, of: (check any that apply) ■ Any needed organs and/or tissues ■ The following organs and/or tissues

■ Limitations If you do not state your wishes or instructions about organ and/or tissue donation on this form, it will not be taken to mean that you do not wish to make a donation or prevent a person, who is otherwise authorized by law, to consent to a donation on your behalf. Your Signature Date

(7) Statement by Witnesses (Witnesses must be 18 years of age or older and cannot be the health care agent or alternate.) I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence. Witness 1 Date Name (print) Signature Address

Witness 2 Date Name (print) Signature Address

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36 Letter from the New York State Department of Health Statewide Planning and Research Cooperative System (SPARCS) This is to notify all hospital patients that the New York State Department of Health has developed a statewide data system known as the Statewide Planning and Research Cooperative System (SPARCS) and that all hospitals are required to submit to SPARCS certain billing and medical record information for all patients. This information in SPARCS will be used for financial studies, rate setting, utilization review, health planning, epidemiology and research studies. Please be assured that under this program: 1. The New York State Department of Health will not receive the name of any patient or any information which will enable a patient to be identified within the SPARCS system. 2. Regulations have been enacted protecting a patient’s privacy and confidentiality by restricting access to any sensitive information in SPARCS and assuring review of all requests by an independent public review board. 3. Regulations have been enacted protecting a patient’s privacy and confidentiality by restricting access to any sensitive information in SPARCS and assuring review of all requests by the Data Governance Committee. 4. SPARCS is not designed to identify specific patients; instead it is structured to provide information on patterns of illnesses and costs of care in hospitals. This hospital is required to submit patient medical record and billing data to the Department of Health pursuant to Section 400.18 of Article 1, Subchapter A, Chapter V, Title 10 (Health) of the OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK. The privacy, confidentiality and security of the information supplied is protected pursuant to Section 400.18(e) of Article 1, Subchapter A, Chapter V, Title 10 (Health) of the OFFICIAL COMPILATION OF CODES, RULES AND REGULATIONS OF THE STATE OF NEW YORK. For further information concerning SPARCS, please contact: SPARCS Operations Bureau of Health Informatics Office of Quality and New York State Department of Health Empire State Plaza Corning Tower, Room 878 Albany, New York 12237 Phone: (518) 473-8144 Fax: (518) 486-3518 Questions/Comments: [email protected] Data Requests: [email protected]

Hospitals must provide patients with a notification letter from the New York State Department of Health that relates to the statewide data collection system known as SPARCS 10NYCRR, 400.18 (b) (2) and (C) (2) (SPARCS Letter)

37 Maternity Information Hospitals (and birth centers) must provide a copy of the Breastfeeding Mothers’ Bill of Rights and the Maternity Information Leaflet to maternity patients or their appointed representative (at the time of pre-booking, attendance at prenatal childbirth education classes or at admission) and to the general public, upon request. The Breastfeeding Mothers’ Bill of Rights requires that women are informed of the hospital’s obligation to provide breastfeeding instruction, assistance and support and information about the benefits of breastfeeding that is free of commercial interests. This information will inform you about what to expect, your childbirth choices and rights, and help you plan for your baby’s birth. The Maternity Information Leaflet includes information about your hospital’s maternity-related procedures and practices. The hospital-specific statistics and the average statistics for all NY hospitals that provide maternity care are updated yearly. This allows you to compare your hospital’s statistics to other NY hospitals regarding the type of deliveries (e.g., Cesarean sections), the use of selected procedures during birth, breastfeeding rates, or the availability of birthing rooms or rooming-in. • Inpatient insurance coverage in New York State is provided for a mother and her newborn for at least 48 hours after childbirth for vaginal delivery and at least 96 hours after a Cesarean section. In addition, each hospital must provide patient education, assistance and training in breast or bottlefeeding and any necessary maternal or newborn clinical assessments. Check with your insurance company for more details on your maternity coverage. • Maternal depression or baby blues may occur after giving birth. Your body has undergone physical and hormonal changes, which may leave you with feelings of sadness, mood swings, anger, anxiety and low self-esteem, for days or weeks following birth. The baby blues are very common and will pass in time. Your doctor can suggest some ways to help you feel better. Less common is maternal depression. The symptoms are severe and can include feelings of hopelessness, high anxiety, eating problems, feeling “out of control,” and thoughts of harming yourself or the baby. Contact your doctor regarding these symptoms, as maternal depression is treatable. Your doctor must be contacted immediately if you feel as though you may hurt yourself or your baby. • Shaken baby syndrome refers to the injuries that result from the violent shaking of an infant or child. New parents need to be aware of the danger of shaking their infant or small child. Many times, a frustrated caregiver loses control and shakes an infant in an attempt to stop the baby from crying. Often, there is no intent to harm the child, just to have the baby stop crying. The stress of caring for a newborn can place any caregiver, including parents, at risk for shaking a baby. Before you leave the hospital, you will be asked to watch a video about the dangers of shaking infants and young children. You will be asked to sign a form that you either saw the video or refused to see it. For more information about shaken baby syndrome, visit the Department of Health website at health.ny.gov/prevention/injury_prevention/shaken_ baby_syndrome/. • Safe sleep space and positioning are important to keep babies from dying unexpectedly from sleep-related causes. Babies should sleep alone, on their backs and in a safe crib for naps and at night. The crib should have a firm mattress and fitted sheet. Room sharing without bed sharing is recommended. Babies should not sleep on a couch or chair. You will be given more information about safe sleep before you bring your baby home from the hospital or birth center. Visit the Department of Health website at health.ny.gov/publications/0672/.

10NYCRR, 405.21 (c) (8) (iii): Hospitals must assure the availability of prenatal childbirth education classes for all pre- booked women which addresses pregnancy, labor and delivery; infant care and feeding; breastfeeding; parenting; nutrition; effects of smoking, alcohol and other drugs on the baby; and newborn screening. Public Health Law, § 2803-j: Information for maternity patients Public Health Law, § 2505-a: Breastfeeding Mothers’ Bill of Rights 38 Domestic Violence: Notice for Prenatal and Maternity Patients This notice contains information that will be valuable to you if you are a victim of domestic violence. If you are a victim of domestic violence you should request to speak with someone about your situation and be given this information in a private and confidential manner. Your rights as a patient will be violated if hospital staff asks if you are a victim of domestic violence in front of any accompanying partner or family member.

Are You And Your Baby Safe? You might not be, if there is domestic violence in your life. Here are some questions to help you know if you’re being abused: Does your partner hurt you with words? Does he insult you and make you feel worthless? Does he put you down in front of other people? Does he hurt you physically? Does he push, slap, hit, punch, kick, choke or beat you? Does he make you do sexual things you don’t want to do or hurt you during sex? Is he in charge of everything? Does he tell you who you can and cannot see or talk to? Does he control all the family’s money? Does he scare you? Does he lose his temper, get very jealous or break things? Does he threaten to hurt you, the kids, pets or himself? Victims of domestic abuse are not always physically hurt. If you answered “yes” to any of the questions above, you might be abused. You or your children could be in danger. You are not alone. You are not to blame. You do not deserve to be abused. Did you know that domestic violence sometimes starts or gets worse during pregnancy? And you’re not the only one getting hurt: • A woman who is abused during pregnancy may be more likely to have a miscarriage, infections, bleeding, anemia and other health problems. These can affect both her and her baby. • She is twice as likely to have a low birthweight baby. • Most men who hit their partners also beat their children. Some also sexually abuse children. • Kids whose fathers beat their mothers can suffer from health problems, sleep problems, anger, guilt, fear and anxiety. • Each year, more than 1,000 children in the U.S. die from injuries caused by their parents, guardians or others.

39 You and your baby do not deserve to be treated this way. You have a right to be safe. Help is available. What type of help do you need? The services listed below are available in most communities. Anything you say is confidential. • Hotlines: a counselor will talk to you on the phone and give you information, or just listen. She or he will also tell you places near you to call or go to for more help, if you want it. Hotline numbers are listed below. • Support groups: you can talk with other women who have gone through what you’re going through (a support group). It can help you feel less alone and you can share ideas and information on safety. • Services for children: many programs have counseling and support for kids to help them understand what is happening. It gives them a chance to talk about their feelings. • Advocacy and other support services: someone can help you through the “system.” This person is a domestic violence advocate. Advocacy services often include help finding legal advice, counseling, health care, housing, a job and social services. • Police and the courts: police can help in many ways, such as getting you and your children to a safe place in an emergency. Family and criminal courts can help by issuing an order of protection or by deciding custody, visitation or child support. • Shelters: most counties have shelters and safe homes where you and your children can stay. Shelters can help you get many of the services listed above. No one “asks for it,” and no one should have to live in fear. You New York State Hotlines owe it to your children to keep NYS Domestic & Sexual Violence Hotline: 1-800-942-6906 them — and yourself — safe. CONFIDENTIAL 24 HRS/7 DAYS English & Espanol, multi-language accessibility You are not alone. Deaf or Hard of Hearing : 711 Help is available. In NYC: 311 or 1-800-621-HOPE (4673) TDD: 1-866-604-5350 For additional resources to NYS and National (Youth, Military, LGBT) resources: Office for the Prevention of Domestic Violence: http://www.opdv.ny.gov/ Rape Crisis and Sexual Violence Prevention Program: https://www.health.ny.gov/prevention/sexual_violence/ resources.htm Office of Children & Family Services To report child abuse: 1-800-342-3720 National Committee to Prevent Child Abuse: 1-800-342-7472 Prevention information and parent help-line

Public Health Law 2803-p Disclosure of Information Concerning Family Violence

40 Domestic Violence: Victim’s Rights Notice The Victim’s Rights Notice was prepared to inform victims of domestic violence, of their legal rights and remedies available under the law. If you are a victim of domestic violence you are encouraged to request to speak privately with a social worker or someone who can help you. You should be interviewed privately out of eyesight or earshot of anyone who accompanies you. Your rights as a patient will be violated if hospital staff asks if you are a victim of domestic violence in front of any accompanying partner or family member.

If you are the victim of domestic violence: The police can help you: • get to a safe place away from the violence; • get information on how the court can help protect you against the violence; • get medical care for injuries you or your children may have; • get necessary belongings from your home for you and your children; • get copies of police reports about the violence; or • file a complaint in criminal court, and tell you where your local criminal and family courts are located. The courts can help: • You have the right to take your case to the criminal courts, the family court or both. • The forms you need are available from the family court and the criminal court. • The courts can decide to provide a temporary order of protection for you, your children and any witnesses who may request one. • The family court may appoint a lawyer to help you in court if it is found that you cannot afford one. • The family court may order temporary child support and temporary custody of your children. New York Law States: “If you are the victim of domestic violence, you may request that the officer assist in providing for your safety and that of your children, including providing information on how to obtain a temporary order of protection. You may also request that the officer assist you in obtaining your essential personal effects and locating and taking you, or assist in making arrangements to take you and your children to a safe place within such officer’s jurisdiction, including but not limited to a domestic violence program, a family member’s or a friend’s residence, or a similar place of safety. When the officer’s jurisdiction is more than a single county, you may ask the officer to take you or make arrangements to take you and your children to a place of safety in the county where the incident occurred. If you or your children are in need of medical treatment, you have the right to request that the officer assist you in obtaining such medical treatment. You may request a copy of any incident reports at no cost from the law enforcement agency.” “You have the right to seek legal counsel of your own choosing and if you proceed in family court and if it is determined that you cannot afford an attorney, one must be appointed to represent you without cost to you. You may ask the district attorney or a law enforcement officer to file a criminal complaint. You also have the right to file a petition in the family court when a family offense has been committed against you. You have the right to have your petition and request for an order of protection filed on the same day you appear in court, and such request must be heard that same day or the next day court is in session. Either court may issue an order of protection from

41 conduct constituting a family offense which could include, among other provisions, an order for the respondent or defendant to stay away from you and your children. The family court may also order the payment of temporary child support and award temporary custody of your children. If the family court is not in session, you may seek immediate assistance from the criminal court in obtaining an order of protection. The forms you need to obtain an order of protection are available from the family court and the local criminal court. The resources available in this community for information relating to domestic violence, treatment of injuries, and places of safety and shelters can be accessed by calling the following 800 numbers. Filing a criminal complaint or a family court petition containing allegations that are knowingly false is a crime.”

Get Help Now Get Safe Stay Safe Call: 1-800-942-6906 (English and Espanol) (24 hours) or call your local Domestic Violence Program

Public Health Law 2803 (1) (h) Notice to Victims

42 Parents’ Bill of Rights As a parent, legal guardian or person with decision-making authority for a pediatric patient receiving care in this hospital, you have the right, consistent with the law, to the following: 1) To inform the hospital of the name of your child’s primary care provider, if known, and have this information documented in your child’s medical record. 2) To be assured our hospital will only admit pediatric patients to the extent consistent with our hospital’s ability to provide qualified staff, space and size appropriate equipment necessary for the unique needs of pediatric patients. 3) To allow at least one parent or guardian to remain with your child at all times, to the extent possible given your child’s health and safety needs. 4) That all test results completed during your child’s admission or emergency room visit be reviewed by a physician, physician assistant, or nurse practitioner who is familiar with your child’s presenting condition. 5) For your child not to be discharged from our hospital or emergency room until any tests that could reasonably be expected to yield critical value results are reviewed by a physician, physician assistant, and/or nurse practitioner and communicated to you or other decision makers, and your child, if appropriate. Critical value results are results that suggest a life- threatening or otherwise significant condition that requires immediate medical attention. 6) For your child not to be discharged from our hospital or emergency room until you or your child, if appropriate, receives a written discharge plan, which will also be verbally communicated to you and your child or other medical decision makers. The written discharge plan will specifically identify any critical results of laboratory or other diagnostic tests ordered during your child’s stay and will identify any other tests that have not yet been concluded. 7) To be provided critical value results and the discharge plan for your child in a manner that reasonably ensures that you, your child (if appropriate), or other medical decision makers understand the health information provided in order to make appropriate health decisions. 8) For your child’s primary care provider, if known, to be provided all laboratory results of this hospitalization or emergency room visit. 9) To request information about the diagnosis or possible diagnoses that were considered during this episode of care and complications that could develop as well as information about any contact that was made with your child’s primary care provider. 10) To be provided, upon discharge of your child from the hospital or , with a phone number that you can call for advice in the event that complications or questions arise concerning your child’s condition.

Public Health Law (PHL) 2803(i)(g) Patients’ Rights 10NYCRR, Section 405.7

Department of Health 1470 11/17

43 44 45 Questions or Comments: [email protected]

Department of Health

Follow us on: health.ny.gov facebook.com/nysdoh twitter.com/HealthNYGov youtube.com/nysdoh 1449 Revised 3/19